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HomeMy WebLinkAboutCongregational Church 7/10/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: STREET FAIR -FAMILY FUN NIGHT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. Whose place of business is: CONGREGATIONAL CHURCH OF MANSFIELD - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: Permit Expires: ,July 10, 2018 Food Fee: License Number: FFN-4 WAIVED BOARD OF HEALTH Michael wMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By a�� d f� it Mansfield Family Fun Nightm Food Establishment Permit Application -- --3 Establishment Name: /'�� 11 1,©�� rkTtOnctiI k o{. Establishment Address: 1.7- UO(S+ $;-FP.ee+ Establishment Mailing Address (if different): kl /t n S'�oaD ya Establishment Telephone No: c3 l._I q Applicant Name & Title: e {- Applicant Mailing Address:,) i I Lo-n+e f,r-\ .LCLOe Applicant Phone Number: � � L/ Applicant Email: Ji 0k1g5;or\t`✓ MVIO-ry\ • Olt- Establishment Owned By: An association Water Source: Town A corporation Sewage disposal: Town An individual A partnership Other le al entit Days and Hours of Operation: 4PM to Midnight Location: Street Fair Establishment Type Snack Food Operations: PHF- potentially hazardous food(time/temperature controls required) (Check all that apply) Definitions: Non-PHFs - non- potentially hazardous food (no time/temperature controls required) RTE- ready -to -eat foods Ex, sandwiches, salads, muffins which needno furtherprocessing) ❑ Distribution of Commercially Pre -Packaged candy or bottled drinks Preparation and distribution of popcorn, cotton candy, open hot and cold drinks. Distribution of foods that are cut up and served. Other (Describe): y, To be completed by the Board of Health WC ttii II bc- Se-r"t/�h J j�re.- mr��, ie.yYtOyuJe- 61 l r�R-- otal Permit Fee: FEE WAIVED evP l str� hv�� Shorics ktS (IWSCU. Is UV- ewt in jnc,11 f I Sc-oope d RPM eS Q ce- pc cic c�e,1 O>1tPped I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on hovnd d5tW copiespk105 CMR 590.000 and the federal Food Code. Signature of Applicant: ra 3 Pursuant to MGL Ch.682C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: - C LL[ !� TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Sign re of Individual or torpc&e Name 113= �)-7So LASsO ; 38$ *'Social Security No. (Voluntary) g eral rdentii6cationNum er *This license will not be issued unless this certification clause is signed by the applicant. **Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: s) �rf U City/State/Zip: Phone #: S0 3 —3 3 9 - 417 0 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. 8.on-profit [No workers' comp. insurance required] Nntertainment 3. ElWe are a corporation and its officers have exercised 9. then' right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑Health Care 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the papisiand penalties ofperjuty that the information provided above is true and correct. -36® --,23 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other IIContact Person: Phone #: www.mass.gov/dia Mansfield Board of Health Waiver 2018 for Food Permit Date *Put the name of your restaurant on first line then sign the form. !=EIATXR'OA"ff'MJ7)PiXWIW,M.iM,AA MI, Food Service Permit Fee for the following Thank you, Family Fun Night 2018 Title